November 14, 2013

Should flu vaccines be mandatory for health care workers? That's the question raised this week in the British Medical Journal to two researchers, including Penn Medicine's Amy J. Behrman, MD, in a "Head to Head" piece that argues both sides of the debate.

Behrman, the medical director of Occupational Medicine Services at the Hospital of the University of Pennsylvania and associate professor of Emergency Medicine in the Perelman School of Medicine at Penn, believes that mandatory vaccination is needed to protect vulnerable patients, while an emergency department nurse from Vancouver General Hospital in Canada argues that evidence on effectiveness is not sufficient to over-ride health care workers' right to choose.

Both authors cite past studies and raise ethical issues to make their case.

Influenza vaccines are not only estimated to prevent thousands of hospital admissions and millions of illnesses annually, but they are also safe and have the greatest protective effect in healthy non-elderly adults, precisely the demographic of most health care workers, Behrman states.

For this reason, vaccinating hospital staff can improve patient safety, as well as protecting health care workers. Mandatory staff vaccination help protect patients who are at the highest risk for influenza complications and most likely to be in a hospital setting: elderly people, infants, patients with heart and lung disease, and patients with compromised immune systems.

"Health care institutions should maximize the use and benefit of a vaccine that is moderately effective, extremely safe, and logically likely to reduce the risk of healthcare acquired influenza for vulnerable patients as well as decrease illness among health care workers," Behrman writes. "First do no harm."

Ideally, workers will take individual responsibility for being fully immunized, but when that does not occur, health care institutions have an ethical obligation to intervene, just as they do to optimize hand washing and minimize surgical site errors, she said.

In 2009, the University of Pennsylvania Health System approved a mandatory policy for all staff, after extensive efforts to improve voluntary immunization rates were insufficient, and after an internal survey on attitudes toward immunization mandates found overwhelming medical staff support.

The health care provider from Vancouver General Hospital, on the other hand, argues that vaccinating health care workers has not been shown to reduce the transmission of influenza to patients by rigorous criteria. A recent Cochrane review of five studies found no evidence that vaccinating health care workers prevents influenza or its complications in individuals in long term care, and thus no evidence to mandate compulsory vaccination, he states.

He also notes that the vaccine often only imparts partial immunity and may last for less than the entire flu season.

Health care workers, according to him, should protect patients from influenza by isolating people with symptoms of respiratory infection, improving infection control, covering coughs, washing hands, and staying home when sick. For him, influenza vaccination should remain a personal decision until there is more persuasive evidence.